68 year old female with Altered sensorium since 2 days

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CHIEF COMPLANTS:-

Patient was brought to the casualty with the c/o altered sensorium since 2 days

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 2weeks back then she developed vomitings 5 episodes which is non bilious,non projectile,food particles as a content associated with nausea treated with iv fluids at local hospital.

Loss of appetite,generalised weakness from 2 days,altered sensorium worsened,intermittently gaining Orientation

H/o burning micturition

No h/o fever,loose stools

No h/o constipation

No h/o chest pain, palpitations,sob

No h/o seizures,loss of consciousness and headache.

PAST HISTORY:-

K/c/o HTN since 20 yrs on Tab.telmisartan 40mg+clinidipine+chlorothiazide 12.5mg

K/c/o DM since 20 yrs on Tab.glimiperide 1mg +metformin 500mg

O/e:

Patient is drowsy, 

MMSE:

Orientation to time:1

Orientation to place:2

Registration:3

Attention:0

Recall:2

Naming:3

Repeatation:0.5

Read and follow commands:1

Sentence:0.5

Copying:0

Score:13/30

GENERAL EXAMINATION:-

Patient is conscious , coherent & co-operative

Moderately built and nourished.

No signs of pallor, icterus, clubbing, cyanosis, pedal edema and lymphadenopathy.

Vitals:-

Temp:98.6F

PR:84bpm

RR:19 cpm

BP:120/70mm.hg

Spo2:99%

GRBS:164 mg%

SYSTEMIC EXAMINATION:-

CNS:-

Patient is drowsy, 

MMSE:

Orientation to time:1

Orientation to place:2

Registration:3

Attention:0

Recall:2

Naming:3

Repeatation:0.5

Read and follow commands:1

Sentence:0.5

Copying:0

Respiratory system:-

Bilateral air entry present 

NVBS heard

Cardiovascular system:-

S1, S2 heard

Abdomen:-

Soft, Non tender

INVESTIGATIONS:-

Chest X ray

Hemogram

Cue

LFT

RFT

RBS

HbA1C

Serology:-negative

Serum osmolality

Urinary electrolytes:-

USG

ECG

2D Echo

Serum electrolytes:-

26/5/23

27/5/23

28/5/23

29/5/23

PROVISIONAL DIAGNOSIS:-

Altered Sensorium with Dyselectrolytemia

TREATMENT:-

On 27/05/23:-

1)IV fluids 0.9%NS@ 50ml/hr

2)Inj. optineuron 1 amp in 100ml NS/IV/OD

3)Inj.HUMAN ACTRAPID INSULIN S/C TID 

4)Tab. TELMISARTAN 40MG PO/OD

5)SYP.CREMAFFIN PLUS 15ml/PO/STAT

6)Vitals monitoring 2 hrly

On 28/05/23:-

1)IV fluids 0.9%NS@ 50ml/hr

2)Inj. optineuron 1 amp in 100ml NS/IV/OD

3)Inj.HUMAN ACTRAPID INSULIN S/C TID 

4)Tab. TELMISARTAN 40MG PO/OD

5)SYP.CREMAFFIN PLUS 15ml/PO/STAT

6)Vitals monitoring 2 hrly

On29/05/23:-

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) ARISTOZYME PO/TID

4)Inj.HUMAN ACTRAPID INSULIN S/C TID 

5)Tab. TELMISARTAN 40MG PO/OD 

6) SYP.CREMAFFIN PLUS 15ml/PO/STAT

7) Vitals monitoring 2 hrly

8) GRBS monitoring

On 30/5/23:-

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) ARISTOZYME PO/TID

4)Inj.HUMAN ACTRAPID INSULIN S/C TID 

5)Tab. TELMISARTAN 40MG PO/OD 

6) SYP.CREMAFFIN PLUS 15ml/PO/STAT

7) Vitals monitoring 2  hrly

8) GRBS monitoring

Soap notes:-

On 27/05/23:-

S:-Generalized weakness

stools not passed

MMSE- 18/30

O:-

Patient is c/c/c

Temp:- 98

PR- 76bpm

RR - 18cpm

BP- 110/70mmHg

GRBS- 158mg%

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender.

CNS - NFND

A:-ALTERED SENSORIUM 

DYSELECTROLYTEMIA

P:-

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) Inj.HUMAN ACTRAPID INSULIN S/C TID 

4)Tab. TELMISARTAN 40MG PO/OD

5) SYP.CREMAFFIN PLUS 15ml/PO/STAT

6) Vitals monitoring 2 hrly

On 28/05/23:-

S:-Generalized weakness

stools not passed 

MMSE- 22/30 

O:-

Patient is c/c/c

Temp:- 98.4F

PR- 82bpm

RR - 18cpm

BP- 120/8mmHg

GRBS- 153mg%

ELECTROLYTES

26/5 27/5 28/5

Na+-130 135 140

k+- 3.3 3.2 3.5

cl- 95 98 105

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender, bowel sounds heard

CNS - NFND

A:-ALTERED SENSORIUM 

DYSELECTROLYTEMIA

P:-

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) Inj.HUMAN ACTRAPID INSULIN S/C TID 

4)Tab. TELMISARTAN 40MG PO/OD

5) SYP.CREMAFFIN PLUS 15ml/PO/STAT

6) ENEMA

7) Vitals monitoring 2 hrly

On 29/05/23:-

S:-Generalized weakness present .

stools not passed 

MMSE- 24/30 

O:-

Patient is c/c/c

Temp:-afebrile

PR- 86bpm

RR - 20cpm

BP- 140/80mmHg

GRBS- 134mg%

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender, bowel sounds heard

CNS - NFND

A:- ALTERED SENSORIUM 

DYSELECTROLYTEMIA

P:-

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) ARISTOZYME PO/TID

4)Inj.HUMAN ACTRAPID INSULIN S/C TID 

5)Tab. TELMISARTAN 40MG PO/OD 

6) SYP.CREMAFFIN PLUS 15ml/PO/STAT

7) Vitals monitoring 2 hrly

8) GRBS monitoring

On 30/5/23:-

S:-Generalized weakness present .

stools not passed 

MMSE- 24/30

O:-

Patient is c/c/c

Temp:-afebrile

PR- 86bpm

RR - 20cpm

BP- 140/80mmHg

GRBS- 134mg%

CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender, bowel sounds heard

CNS - NFND

A:-A ALTERED SENSORIUM 

DYSELECTROLYTEMIA

P:

1)IV fluids 0.9%NS@ 50ml/hr

2) Inj. optineuron 1 amp in 100ml NS/IV/OD

3) ARISTOZYME PO/TID

4)Inj.HUMAN ACTRAPID INSULIN S/C TID 

5)Tab. TELMISARTAN 40MG PO/OD 

6) SYP.CREMAFFIN PLUS 15ml/PO/STAT

7) Vitals monitoring 2 hrly

8) GRBS monitoring